Provider Demographics
NPI:1124663232
Name:RAFA, RYAN SCOTT
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:SCOTT
Last Name:RAFA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 WHITE WILLOW WAY
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-6119
Mailing Address - Country:US
Mailing Address - Phone:304-460-5123
Mailing Address - Fax:800-734-8498
Practice Address - Street 1:1005 WHITE WILLOW WAY
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-6119
Practice Address - Country:US
Practice Address - Phone:304-460-5123
Practice Address - Fax:800-734-8498
Is Sole Proprietor?:No
Enumeration Date:2019-11-12
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2428363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program